Gynecologic derived from the Greek words gyne or gynaikos meaning woman or female and logia meaning study,

, Thus, gynecology means the study of diseases of women. Gynecology of Infancy and Childhood the oncept of gynecology includes developmental defects, anomalies and diseases of the reproductive organs in females of all ages from infants to elderly women. This broadened concept acknowledges equal rights for young and old alike, especially as applied to preventive and therapeutic aspects. Pelvic evaluation at an early age may not only be desirable but in some cases maybe a necessity. Considerations in the Gynecological exam in childhood: 1. Anatomic consideration places emphasis on the infantile of small size of the reproductive organs. 2. Special techniques may be required because of the immaturity of the reproductive organs. 3. The exam may have possible emotional effect, both immediate and n the future. Parental reactions have much to do with this. 4. The nurse should have patience, reassurance and avoid things that will likely cause pain. Gynecologic Geriatrics refers to changes in the reproductive organs due to aging. 1. Menopause cessation of menstruation, change n life or grand climacteric 2. Physical Changes: a. gradual atrophy of the reproductive tract b. vulva loses contour and tumescence c. labia shrinks d. vaginal mucosa becomes thinner and smooth e. uterus gets smaller and firm f. ovaries become small, firm and atrophic g. breasts lose fullness and reveals atrophy and shrinkage 3. Subjective symptoms: a. hot flushes especially at night due to vasomotor phenomena limited to the upper part of the thorax, head and neck. This is usually followed by redness of the skin and perspiration. This may be controlled by the use of estrogen, sedatives or both. b. menopausal dyspareunia due to thinning of the vaginal mucosa and decreased function of the mucus secreting cervix and Bartholins glands. c. unnecessary fears and baffled thoughts Nursing Care Principles: 1. History taking should include: a. Menstrual cycle b. Marital and sexual history o. Obstetrical history

d. Previous surgeries or illness e. Bowel and urinary assessment f. Associated organs review g. Presenting problem 2. Provision of privacy 5, Psychological Preparation A. Normally, women associate these organs with femininity aside from reproductive function and sexual symbolism. B. Women may experience difficulty in accepting manipulation of these organs during tests and treatments. C. The nurse who s sensitive to the many thoughts and fears, feelings of humiliation and guilt, embarrassment and anger that may trouble the patient is better prepared to help her accept the necessary medical exam. D. It often reassures the patient that medical information will be given only to the doctor and goes no further. E. The patient should know that complete, frank answers to the questions of the doctor will help considerably in determining the cause of any difficulty in planning suitable treatment. F. The woman should be prepared for the questions she will be asked: like monthly periods, pregnancies, deliveries, etc G. She should be given a chance to think through her answers under less pressure and thus give more accurate information. H. Explain to the patient the procedure that will be performed, what she is expected to do and what the doctor will do. I. A calm, thoughtful, interested, yet matter of fact manner often helps patient to be at ease. The nurse should however appraise each patient and adjust her approach accordingly. J. Reassure the patient that the nurse will be present during the entire procedure. K. Ventilation sessions may provide the nurse an opportunity to clarify misconception that the patient may have. Some examples are: + Removal of uterus means induction of menopause + A radical hysterectomy (without vaginoanatomy) means that ones sexual life is terminated , + Removal of the reproductive organs makes a woman less womanly + Removal of the ovary produces sterility + Suspicious Paps smear positively establishes the diagnosis of malignancy L Every effort to maintain the patients privacy, to understand her emotional liability and to listen to her expression of needs must continue.

GYNECOLOGIC PROCEDURES 1. Diagnostic A. Schillers test for Ca - cervix is painted with tincture of iodine - color change in the cervix is noted Mahogany brown stain negative result

No staining positive result B. Papanicolau test cytologic test for Ca Uses: To detect precancerous lesions To detect recurrence of Ca To evaluate endometrial status Subjects: Women 20 years above Sexually active women done regularly Preparations: No sexual activity during preceeding 24 hours No lubricant used No vaginal tablets for 2-3 nights before No perineal douche before the exam Procedure: Aspirate or swab vaginal secretions from the posterior fornix and make a smear on the glass with light rolling motion, Do not let smear become dry, immerse immediately in a fixing solution of ethanol 95% Result: Has 90-95% accuracy for cervical Ca 70-75% accuracy for severe dysplasia 80% accuracy for endometrial Ca Class 1 absence of atypical or abnormal cells

Class 2 atypical cytology but no evidence of malignancy Class 3 cytology suggestive but not conclusive of malignancy Class 4 cytology strongly suggest Ca Class 5 cytology is conclusive of Ca Note: Class 1-4 additional diagnostic exams as biopsy and D&D C. Cervical biopsy and Cauterization removal of small bits of tissue from the cervix for diagnostic purposes. Electrocauterizationis done afterwards to control bleeding from the site or to remove additional tissue. Post Biopsy instructions: + Avoid heavy work for 24 hours Avoid heavy lifting + Cervical packing remains in place and removed after 24 hours Sexual activity is resumed with doctors order usually 2-3 weeks after + Complete epithelialization is expected n 2-3 months + Increase in vaginal secretions is expected for 2-3 days D, Culdoscopy visualization of the internal reproductive organs by inserting a tubular lighted instrument (culdoscope) through an incision made in the posterior fornix of the vagina into the cul-de-sac of Douglas. Preparations: Knee chest Home care instructions: + No douches and sexual activity for I week : Watch out for complications like infection, hemorrhage and air embolism .:. The incision should heal rapidly E. Lapacscopy abdomen s insufflated with C02 and a trocar is introduced through the lower portion of the umbilicus. A laparoscope is inserted and pelvic organs are vsa ze:. This is a diagnostic aid to determine ectopic pregnancy, inflammatory disease and ovarian neoplasms.

F. Hystero-Salpingogram X-ray study of the uterus and the fallopian tubes after the injection of a contrast medium through the cervix via a cannula (indigo-carmine dye) Purposes: + Study problems of sterility . Evaluate tubal patency + Determine the presence of uterine pathology Position: Uthotomy . Result: If tubes are patent the dye can be visualized passing out the fimbriated end of the fallopian tubes. G. Rubins test determine tubal patency. C02 is passed through the cervix into the uterus and tubes. If patent, gas will pass through the fimbriated ends of the fallopian tubes into the peritoneal cavity and will give a sensation of fullness and spasmodic shoulder pains due to severe irritation from the gas. H. Sims-Hunners test post coital exam a specimen of seminal fluid from posterior fornix and cervical canal is aspirated 2-4 hours after coitus. Purposes: Test for compatibility of sperms with cervical mucus Determine husbands ability to deposit normal motile sperms in sufficient amount I. Semen analysis examination of the semen for number and motility J. Ultrasound simple, safe and inexpensive procedure which causes or uses sound waves of a transducer and scan oscilloscope.

University of Santo Tomas College of Nursing K. Computerized Tomography instead of just a single X-ray source and film, there is an X-ray source moving around the patient with special detectors opposite the X-ray source. The computer translates the X-ray film taken on the patient and projects it on the HIV screen. INDIRECT FHR MONITORING This involves placing an instrument on the pregnant abdomen that FHR through uterine and abdominal wall. It is simple to apply and can be used before the membranes rupture or if the cervix is dilated. Instruments used: 1. Head stethoscope 2. Ultrasound transducer Doppler principle DIRECT FHR MONITORING By fetal electrocardiography presenting part after membranes rupture Risk: Scalp abscess, postpartum endometritis 1. Decelerations: transient fall of FHR a. Early, normal, negative occurs during contractions b. Late, abnormal, positive 30-40 seconds after each contractions = utero placental insufficiency c. Variable unpredictable = cord compression NON STRESS TEST FHR increases in response to fetal movement, uses external fetal monitor Results:

Negative Reactive FHR accelerates n response to movement Positive Non Reactive FHR does not accelerate with fetal movement STRESS TEST 1. Nipple stimulation stress test 2. Oxytocin challenge test (OCT) Oxytocin infused per IV with 1 m.u. initially and increased every 5-15 minutes until 3 contractions are experienced n 10 minutes. indicated for DM, Toxemia, IUGR, Post terra, Rh incompatibility Results: Negative Reactive No late decelerations Positive Non reactive Consistent and persistent late decelerations

GYNECOLOGIC DISORDERS I. Menstrual Dy3functions A. Amenorrhea absence of menstruation anytime between puberty and menopause (not a disease but a symptom) 1. Primary failure of menstruation to appear initially at puberty 2. Secondary cessation of menstruation after menarche a. Physiologic normal absence before puberty, during pregnancy, lactation and menopause . b. Cryptomenorrhea or Pseudomenorrhea menstruation occurs but does not appear externally because of obstruction in the lower genital organs . c. Pathological due to some pathological diseases of the reproductive system B. Oligomenorrhea reduction in frequency of menstruation or prolongation of interval abnormally, usually from 38 days to 3 months C. Polymenorrhea interval is shortened or more frequent occurrence of menses, usually every 20 days D. Hypomenorrhea scanty menstrual flow without relation to frequency E. Hypermenorrhea or Menorrhagia excessive menstrual flow F. Metrorrhagia bleeding or spotting without obvious relation to menstrual cycle. Also known as intermenstrual bleeding. G. Dysmenorrhea painful menstruation with spastic. crampy arid congestive pains

a. Membranous dysmenorrheal caused by the removal of the endometrium as one piece instead of breaking off or sloughing off. Also known as endometrial cast. CAUSES Psychogenic unstable nervous system or psychic trauma especially when related to menstrual period; lack cf knowledge about significance and normality of menstrual functions. B. Constitutional results from disease conditions as anemia, tuberculosis, DM, overwork or fatigue C. Obstructive or anatomical caused by cervical lesions, stenosis or acute anteflexion of the uterus D. Endocrine factors increased estrogen which is a normal stimulant of uterine contractility

TREATMENT A. Endocrine therapy 1. Use of estrogen in adequate dosage in early part of the cycle to convert ovulatory cycle to unovulatory (inhibition of ovulation brings about relief of pain). 2. Use of Progesterone to suppress ovulation, the drug is given during the first 25 days of the cycle. . B. Pre-sacral neurectony gives complete relief of pain in 60-70% patient cases. C. Treatment during attacks: . 1. local use of heat 2. anIgesics 3. antispasmodics D. Psychotherapy POSSIBLE CAUSES 0F MENSTRUAL DYSFUNCT1ONS A. Neurogenic organic lesion or idiopathic hypothalamic dysfunction B. Pituitary insufficiency of hormones, tumors or congenital defect C. Psychogenic - minor or major psychosis D. Chronic illness E. Metabolic diseases of the pancreas, thyroid and adrenals F. Nutritional disturbances like malnutrition G. Ovarian as in tumors or congenital defects H. Congenital causes like imperforate hymen, absence of vaginal septum (gynatresis) L Traumatic like stenosis of vagina or cervix due to trauma GENERAL METHODS OF TREATMENT Each patient must be treated according to etiologic factor. A. Steroid therapy designed to trigger pituitary functions B. Gonadotropic therapy - designed to replace pituitary hormones C. Clomiphene therapy stimulate pituitary activity through the hypothalamus D. Hypothalamic hormone stimulation which directly stimulate synthesis and release of pituitary gonadotropins (under research) E. Good nutrition Il. Dysfunctional Uterine Bleeding . - Abnormal bleeding from the uterine associated with tumor and inflammations. It is apt to occur at the extremes of menstrual life. Major cause is increase in endometrial lining of the uterus or endometrial hyperplasia. , Ill. Unovulatory Bleeding . . - Follicle develops but instead of maturation becomes cystic and then degenerates. IV. Abnormal Menstruation 1. Precacious appearance of menarche early in childhood, usually under 9 years of age, usually passages, GI mucous membranes, breasts. There is a question whether they can be really called as menstruation.

ANOMALIES AND MALFORMATIONS OF THE REPRODUCTIVE ORGANS Genital Anomalies A. Variation in size of the labia minora one labium is larger than the other. B. Agglutination of the labia labia minora and labia majora are held together in the

midline by dense adhesions. 1. Complete 2. Incomplete synechia vulvae C. lmperforate hymen absence of hymenal opening. This is usually treated with excision of the hymen under general anesthesia. D, Rigid hymen the hymenal opening je normal but the membrane is usually firm giving rise to dyspaneuria. E. Congenital absence of the vagina usually associated with the absence of the uterus and with anomalies of the urinary tract. Also termed genesis of the vagina. F. Vaginal anus or atresia ani vaginalis anus and the bowels open into the vagina. Surgical correction 1s necessary. G. Absence of the uterus occurs with absence of the vagina. H. Double or septate vagina vaginal canal is separated into two by a septum. May occur with entirely normal uterus and fallopian tube, It is generally asymptomatic until marriage when it is found to cause dyspaneuria. Excision of the septum is done. I. Infantile uterus presence of immature uterus. J. Unicornuate uterus uterus has only one horn or opening into the fallopian tubes caused by the development of only one Mullerial tube. Ability to conceive depends upon the maturity of the unicornate uterus. K Bicomuate uterus the upper portion of fundus of the uterus is divided into two separate horns, the lower portion fused to form, only one cervix. L Uterus didelphys or double uterus cervix and vagina due to the presence of a complete septum in the midline. M. Uterine displacements: 1. Anteflexion bending forward of the body of the uterus usually seen in small underdeveloped organ. Cause: Gonadal deficiency Cues: Crampy dysmenorrheal Sterility Delayed menarche Management: Stimulation of growth of the uterus, dilatation of cervical canal and curettage. 2. Retrodisplacements backward displacement of the uterus Types: . . a. Retroversion uterus is tilted backward on its transverse axis a greater or less degree with forward rotation of the cervix. b. Retroflexion backward bending of the uterus with the cervix in usual position. C. Retrocession backward bending of the uterus without rotation or bending Causes: , a. Congenital observed in uterus of very young girls b. Acquired + Puerperal due to increased strain on supporting ligaments that when the uterus involutes, the over stretched ligaments can no longer maintain it in normal position. . :

+ Adrenal diseases like inflammatory or endometrioses . Neoplasms as in large uterine myomas which pushe3 the uterus backward or in ovarian tumor located over the uterine body. + Trauma as in sudden falls + Full bladder and rectum Intra-abdominal pressure : Increasad pelvic tilt Variation in length of vaginal walls.

Cues: a. backache b. dysmenorrheal c. fatigue d. bladder irritation e. constipation Treatment: a. Postural knee-chest position which causes air to distend the vagina to allow the freely movable uterus to fall towards the front. b. Binomial position and maintained afterwards with a pessary c. Surgical shortening of the round and sacrouterine ligaments 3. Prolapse of the uterus this is more frequently found in elderly women than in young patients. Causes: a. Increasing laxity and atony cf muscular structures in later life b. Overstretching of the pelvic floor especially of the cardinal ligaments which causes vaginal relaxation. Types: a. First degree when the cervix of the uterus points in the axis of the vagina b. Second degree the cervix is at or near the introitus o. Third degree procedentia uteri, cervix protruses well beyond the vaginal surface, Cues: a, discomfort due to mechanical protrusion of the uterus b. some degree of bearing down and heaviness in the lower abdomen a-d backache due to traction on the uterine ligaments as well as venous congestion produced by the prolapsed c. urinary incontinence d. pelvic drag e constipation f .general fatigue Treatment will depend upon: a. age b. marital status c. general health d. degree of prolapsed

e. presence or absence of associated pathological conditions Treatment may come in the form of: a. Surgical 1. Vaginal hysterectomy suitable for almost massive degree of prolapsed 2. Manchester operation done for lesser degree of prolapsed especially those associated with large cystccoele. This involves cervical amputation. 3. Colpocleisis (Le fort operation) closing the vagina in occasional cases of massive procedentia. This is performed only in the elderly or widow. Preceded by vaginal hysterectomy. Usually done as a last resort. b. Non-surgical 1. Pessary treatment made of plastic, soft, hand rubber coming in different shapes to fit the needs of the patient Care prior to use: - Wash with soap and water, soak in antiseptic solution for 1 hour - Doctor should assess condition of patient before its insertion Care during its use: - The patient should be aware that it produces an increase in vaginal discharge and asymptomatic irritation - Daily cleansing vaginal douche is required

- The patient should return to the doctor after one week for re-evaluation. If found fit, the doctor will let the patient wear it continuously and tell her to return again for regular check-up . In elderly woman, when operation is not feasible, use of pessary may be desirable for an indefinite period of time. . In young woman, use of pessary usually is a temporary measure. . Types of pessary: o Hard rubber ring o Soft rubber ring o Hard rubber cap o Menges pessary o Glass ball 2. Vaginal Packing occasionally s used to give temporary relief in cases of uterine prolapsed Associated Anomalies With Prolapse: a. Cystocoele occurs as a result of a defect in the pubocervical fiscial plane which supports the bladder anteriorly and tends to permit the bladder to sag down and beyond the uterus and sometimes out of the vagina. b. Rectocoele results from similar mechanism involving the pararectal fascia with a deep posterior fascia which may be drawn farther downward along the anterior surface of the rectum Treatment: Colpoperineorrhapy Anterior for Cystocoele Posterior for Rectocoele

Hermaphroditism Pseudohermaphroditism most common type a. Female essential sex glands are the ovaries but the external genitalia resemble that of the male due to abnormal development. Clitoris is hypertrophied and looks like the male penis, secondary sex characteristics and mental attitude is that of the male. b. Male more frequent essential sex organs and the testes but the secondary sex characteristics and attitude are that of the female. The true sex cannot be easily determined except through a nuclear sex chromatin pattern observed in the smear of cells taken from the epithelium of the mouth, vagina or skin stained by the Paps smear technique. 2. Hermaphroditism combined existence in the same person of both the male and female sex glands commonly associate with malformation of the reproductive organs a. masculinizing influence hypertrophied clitoris, masculine distribution of body hair, masculine type of body configuration and low b. feminizing characteristics rudimentary vagina and uterus and presence of ovarian tissue. This s rare. Infertility - inability to achieve pregnancy within a stipulated period of time usually one year a. Primary the couple has never produced an offspring or has never conceived b. Relative or Secondary inability to conceive following the birth of a child or difficulty in achieving another pregnancy after a previous conception c. Absolute pregnancy is forever impossible Sterility . term used only for individual who has some absolute factor preventing

Factors necessary for normal conception to take place 1. The ovaries must produce at regular intervals normal ova and hormone in sufficient quantity to foster implantation. 2. The female reproductive tract must be patent and normally formed. 3, The testes of the male should be producing healthy sperms of sufficient amount and motility for the fertilization of the ovum. 4. The sperms should be deposited near enough to the cervical canal so that they transverse the uterine canal to meet the ovum. 5. Both the male and female must be in good healthy condition. Sperm Analysis The sperm can be examined on the basis of: 1. quality in terms of content 2. ease at which conception is attained Quality is good if: . Volume per ejaculation 3-5 ml . Number of sperms per ml 60-120 million . 60-80% are actively motile at two hour interval . 85% sperm cells/ejaculation are normal in form

Etiology Causes in the Male (40%) 1. Infection which may obliterate the main sex ducts 2. Trauma or injury which may close the ducts 3. Toxic conditions which may devitalize the germ cell 4. Severe illness leading to physical exhaustion and impotence 5. Insufficient sperm count caused by: a. Disease like orchitis a complication of mumps b. Anomalies of reproductive tract c. Idiopathic tubular atrophy leading to azospermia 6. lmpotence and premature of ejaculation 7. Accidental Causes in Female (60) 1. Infection like endometritis which may obstruct the tubes 2. Immaturity of the reproductive organs 3. Anomalies of the reproductive organs like a. Imperforate hymen b. Absence of vagina c. Tumors 4. Uterine displacement 5. General debility like renal and cardiac disease 6 Disturbed endocrine functions 7. Faulty diet Vitamin C and E Diagnosis: , 1. Thorough history including marital history 2. Complete physical exam of both husband and wife 3. Assessment of ovulation a.BBT b. Spinnbarkheit Spinnbarkeit 4. Urine test for adequate levels of pituitary gonadotropins (FSH and estriol) 5. Endometrial biopsy done on the 218t day of the menstrual cycle to determine f secretory phase is occurring 6. Rubins test to check for tubal patency 7. Hysterosalphingogram 8. Sims Huhners test 9. Semen analysis for quality and motility Treatment: 1. Surgery a. To release adhesions of ducts and reconstruction of the ducts b. To dilate stenosed ducts like the cervix

D. Tuboplasty maintain patency of fallopian tubes through the insertion of polyethylene tubes into them Artificial fmbriae use of plastic like cap fitted at the end of the tube 2. Alpha amylase

3 Hormone therapy a. Clomiphene or Clomid stimulates the hypothalamus to inactivate the pituitary gonadotropins made from frozen dried human pituitaries 4. Appropriate diet, sleep and recreation Inflammatory and Infectious Problems 1. Leukorrhea any discharge from the vagina which is not bloody Norm al during ovulation with a pH of 4.7 (acidic) Abnormal if copious in amount, malodorous with abnormal color, causes irritation and redness of the vulva, accompanied by burning sensation and frequent urination with discomfort and pain in the lower abdominal region This may be caused by: . Foreign body . Infection (gonorrhea, post-partal infection, moniliasis, trichomonas, yeast) . Cervical and uterine disease (polyps) Treatment: . Vinegar douche or plain water (no strong acids or chemicals) . Treatment of specific cause if diagnosed 2, Pelvic Inflammatory Disease (PID) ascending infection after having involved the upper genital tract Causes: . Streptococcus, staphylococcus and gonococcus Symptoms: . Local acute, sharp and severe pain of both sides of the abdomen or pelvis aggravated by defecation. Heavy purulent discharge with foul odor occurs. . Systemic general body malaise, fever and chills, anorexia, vomiting and general aching Infection spreads through blood, lymphatics and through the genital tract.